Management of Locally Advanced and Recurrent Rectal Cancer
Peter Sagar, Andrew G. Hill, Charles H. Knowles, Stefan Post, Willem A. Bemelman, Patricia L. Roberts, Susan Galandiuk, John R.T. Monson, Michael R.B. Keighley, Norman S. Williams in Keighley & Williams’ Surgery of the Anus, Rectum and Colon, 2019
Ligating the internal iliac vein will permit exposure of the lumbosacral trunk as well as the S1, S2 and S3 nerve roots which contribute to the sciatic nerve. The major anti-gravity motor fibres for proximal lower limb muscles are derived from the lumbosacral trunk. Therefore identification and preservation of this is important for lower limb function. The lumbosacral trunk as well as S1, S2 and S3 nerve roots exit the pelvis through the greater sciatic notch which is separated from the lesser sciatic notch by the ischial spine and sacrospinous ligament (Figure 36.4a and b). Both ischial spine and sacrospinous ligament can be identified by tracing the lumbosacral trunk caudally and may also be divided should even wider access to the pelvis be needed. From the ischial spine, arcus tendinous arises which gives rise to the origin of levator ani. Above arcus tendinous is obturator internus, which is lined by the endopelvic fascia anteriorly where it rests on either side of the bladder. Identification of the ischial spine provides a gateway into the anterior-caudal part of the pelvis.
Bernese periacetabular osteotomy
K. Mohan Iyer in Hip Preservation Techniques, 2019
A blunt Homan tractor is placed along the lateral side of the iliac wing to protect the gluteus medius muscle. The medial surface of the quadrilateral bone is stripped subperiosteally. A reverse Homan tractor is placed on the ischial spine. The ischial spine is an important landmark and guidepost. Osteotomy anterior to the ischial spine can ensure that the posterior column of the hemipelvis is intact. A notch is made by wide curved osteotome on the arcuate line in the pelvis, about 1 cm lower than the sacroiliac joint, 3–4 mm superior to the top of the hip joint (Figure 9.1e). The iliac cut is made by oscillating saw from ASIS to the notch (Figure 9.1d).
Pelvic trauma
Sebastian Dawson-Bowling, Pramod Achan, Timothy Briggs, Manoj Ramachandran, Stephen Key, Daud Chou in Orthopaedic Trauma, 2014
Ligamentous structures join the three bones of the pelvic ring (Fig. 15.1). The most important of these are as follows: The posterior SI ligaments are the strongest and most important ligaments of the pelvic ring. They are made up of short oblique and longer longitudinal fibres. The short oblique fibres run from the posterior ridge of the sacrum to the posterosuperior and posteroinferior iliac spines, and the longer longitudinal fibres run from the lateral sacrum to the posterior superior iliac spine and merge with the sacrotuberous ligament.The iliolumbar ligaments run from the fourth and fifth lumbar transverse processes to the posterior iliac crest; the lumbosacral ligaments run from the fifth lumbar transverse process to the sacral ala. Fractures of the L5 transverse process should raise the suspicion of a posterior pelvic ring injury and warrant further investigation with a computed tomography (CT) scan.The anterior SI ligament consists of numerous thin bands, which connect the anterior surface of the lateral part of the sacrum and the ilium.The sacrotuberous ligament is a strong band that runs from the posterolateral sacrum and dorsal aspect of the posterior iliac spine to the ischial tuberosity. This ligament, along with the posterior SI ligaments, provides vertical stability to the pelvis.The sacrospinous ligament runs from the lateral edge of the sacrum and coccyx to the sacrotuberous ligament, and it inserts onto the ischial spine.
Postoperative indications for further surgery following post-transvaginal ProliftTM mesh repair after a two-year follow-up period: a single-centre study
Published in Journal of Obstetrics and Gynaecology, 2022
Hirotaka Sato, Katsuhiko Sato, Junichi Mochida, Satoru Takahashi, Sachiyuki Tsukada
Surgeries were performed at the hospital by a trained urologist, as previously described (Fatton et al. 2007). The surgical technique included a wide dimension, hydro-dissection of the vaginal wall overlying the bladder or rectum, using 50 mL of 1% adrenaline, diluted 1:1,000,000 in 500 mL of normosaline solution. The anterior incision was prolonged in the paravesical space, ischial spine, and arcus tendinous fasciae pelvis (ATFP). The anterior mesh was configured with its two lateral arms on either side, which perforated the obturator foramen at the ATFP level. The posterior mesh configuration consisted of a lateral arm on either side that perforated the sacrospinous ligaments. The artificial implant was a polypropylene mesh (ProliftTM Pelvic Floor Repair System; Ethicon). The vaginal epithelium was closed using continuous absorbable sutures. The ProliftTM surgery type (separated anterior, posterior, or total ProliftTM) was based on the prolapse stage and the compartment. Concomitant surgery including native-tissue repair (e.g. colporrhaphy and perineoplasty) was performed where necessary.
Diagnosis and treatment of pudendal and inferior cluneal nerve entrapment syndrome: a narrative review
Published in Acta Chirurgica Belgica, 2022
Katleen Jottard, Pierre Bonnet, Viviane Thill, Stephane Ploteau, Stefan de Wachter
The PN has been referred to as the king of the perineum [3]. Indeed, the PN plays a major role in the fecal and urinary continence mechanisms and is important for normal sexual functioning. The PN has both motor and sensory functions and carries sympathetic fibers. It arises from the second, third, and fourth sacral ventral rami at the inferior edge of the piriformis muscle [4]. Before entering the gluteal region, the nerve passes through the infrapiriformis foramen, which is a part of the greater sciatic foramen. The nerve then passes posterior from the ischial spine or sacrospinous ligament (SSL), medial to the internal pudendal vessels, to finally enter the perineum through the Alcock’s canal, a fold of the obturator internus muscle fascia. It continues to course through the pudendal canal (Alcock’s canal), giving off three consecutive branches on its path: the inferior rectal (anal) nerve and its branches, the perineal nerve and its branches and the dorsal nerve of the penis or clitoris.
Do Pelvic Organ Prolapse Quantification Examination Ba and D Guide the Selection of Operation for Severe Pelvic Organ Prolapse?
Published in Journal of Investigative Surgery, 2020
Chunbo Li, Huimin Shu, Zhiyuan Dai
Vaginal SSLF was performed unilaterally to the right sacrospinous ligament. In brief, to expose the recto-vaginal and pararectal space, a longitudinal incision in the posterior vaginal wall was made. Blunt dissection was done until the right ischial spines exposly. Two permanent sutures were placed under direct vision through the sacrospinous ligament at least 2 cm from the ischial spine. The sutures were also placed through the uterosacral ligament and the uterus was redressed. For the patients with hysterectomy, after the vaginal cuff was sutured and closed, it was fixed to sacrospinous ligament with nonabsorbable sutures. Neurovascular bundle injuries should be avoided during the operation. At last, the posterior vaginal wall was closed with absorbable sutures.